Nursing Elites

1. A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Elevate the head of the bed to 30°
• B. Flush the tube with 50 mL of water every 2 hours
• C. Replace the feeding bag and tubing every 72 hours
• D. Check the client's gastric residual every 8 hours

Correct answer: A

Rationale: Elevating the head of the bed to 30° is the correct action to take when a client is receiving continuous enteral feedings through a nasogastric tube. This position helps prevent aspiration of the enteral feedings into the lungs, reducing the risk of aspiration pneumonia. Additionally, elevating the head of the bed promotes proper digestion and absorption of the feedings by utilizing gravity to facilitate movement into the stomach and through the gastrointestinal tract. Flushing the tube with water every 2 hours (Choice B) is not necessary for continuous feedings and may disrupt the feeding schedule. Replacing the feeding bag and tubing every 72 hours (Choice C) is not the standard recommendation unless there are specific concerns or complications. Checking the client's gastric residual every 8 hours (Choice D) is important but not the immediate action needed to prevent aspiration during enteral feedings.

2. A client has a new diagnosis of hyperlipidemia and is receiving teaching from a nurse about dietary management. Which of the following statements should the nurse include in the teaching?

• A. You should increase your intake of trans fats.
• B. You should decrease your intake of fiber-rich foods.
• C. You should avoid foods that are high in cholesterol.
• D. You should increase your intake of high-fat foods.

Correct answer: C

Rationale: The correct statement the nurse should include in teaching the client with hyperlipidemia is to avoid foods that are high in cholesterol. Foods high in cholesterol, like those high in saturated and trans fats, can contribute to elevated lipid levels and increase cardiovascular risk. Decreasing intake of these foods can help improve lipid profiles and reduce the risk of complications. Choices A, B, and D are incorrect because increasing intake of trans fats, decreasing fiber-rich foods, and increasing intake of high-fat foods can exacerbate hyperlipidemia and worsen the lipid profile.

3. When planning to perform a sterile dressing change for a client, which of the following actions should a healthcare professional take?

• A. Wear sterile gloves to remove the old dressing.
• B. Cleanse the wound with an antiseptic solution.
• C. Use clean gloves to apply the new dressing.
• D. Open sterile supplies before donning sterile gloves.

Correct answer: D

Rationale: Opening sterile supplies before donning sterile gloves is a critical step in maintaining the sterility of the supplies during a dressing change procedure. By doing so, the healthcare professional ensures that they do not touch non-sterile surfaces with their hands once sterile gloves are worn, reducing the risk of introducing pathogens to the wound and minimizing the potential for contamination.

4. A healthcare provider is planning to administer medications to a client who is receiving enteral feedings through an NG tube. Which of the following actions should the healthcare provider plan to take?

• A. Dissolve each medication in 5 mL of sterile water.
• B. Administer medications through a secondary infusion.
• C. Mix medications with the enteral feeding.
• D. Flush the NG tube with 30 mL of water before and after administering medications.

Correct answer: D

Rationale: Flushing the NG tube with water before and after administering medications is essential to prevent clogging of the tube and ensure proper delivery of medication. This practice helps maintain tube patency and decreases the risk of obstruction, which could compromise the client's treatment and nutrition. By flushing the tube, the healthcare provider ensures that the medication is completely delivered and that there are no residual drug particles left in the tube, which could lead to blockages or inconsistent dosing. Therefore, flushing the NG tube is a crucial step in the safe administration of medications to clients receiving enteral feedings. Choices A, B, and C are incorrect. Dissolving medications in sterile water (Choice A) may not be suitable for all drugs, as some medications may require specific diluents. Administering medications through a secondary infusion (Choice B) is not the standard practice for enteral medication administration. Mixing medications with the enteral feeding (Choice C) can cause interactions between medications and the feeding formula, affecting their absorption and effectiveness.

5. Which of the following statements indicates the client understands the colostomy care instructions?

• A. I will change the colostomy bag once a week.
• B. I will avoid eating high-fiber foods.
• C. I will clean around the stoma with mild soap and water.
• D. I will apply lotion to the skin around the stoma.

Correct answer: C

Rationale: The correct answer is C. Cleaning around the stoma with mild soap and water is crucial for colostomy care as it helps prevent infection and skin irritation. Changing the colostomy bag frequency, dietary modifications, or applying lotion are not primary aspects of stoma care. Proper cleaning around the stoma helps maintain hygiene and prevents complications, making it a key component of caring for a colostomy.

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